Illinois Department of Financial and Professional ...

Illinois Department of Financial and Professional Regulation

Division of Professional Regulation

Request for Reinstatement of Illinois License

PLEASE PRINT License No: _____________________ SSN (Last four only): ______________ Date of Birth: ____________________

First Name: ________________________________ Last Name: ___________________________________________

Address: _______________________________________________________________________________________

City: ________________________________________ State: ____________________ Zip: ____________________

Phone Number: __________________________ Email Address: ___________________________________________

CHECK HERE IF NAME OR ADDRESS CHANGE. A name change must be accompanied by documentary proof. Proof must be a certified copy with an official stamp or seal and be one of the following: Marriage Certificate, Divorce Decree or Court Order.

CHECK THE APPROPRIATE ANSWER BELOW: Are you more than 30 days delinquent in complying with a child support order? NOTE: If you are not subject to a child support order, answer "No".

NO

YES

CHECK THE BOX IF YOU ARE A MILITARY SERVICE MEMBER AND /OR SPOUSE. (P.A. 101-0240) "Service member means any person who, at the time of application under this Section, is an active duty member of the United States Armed Forces or any reserve component of the United States Armed Forces, the Coast Guard, or the National Guard of any state, commonwealth, or territory of the United States or the District of Columbia or whose active duty service concluded within the preceding 2 years before application."

I understand if I provide false/fraudulent information I could lose my license, be fined and/or have other penalties assessed. I also understand the FEES ARE NOT REFUNDABLE. Therefore, I declare that I have examined this form and, to the best of my knowledge, all statements are true, correct and complete.

Signature: ______________________________________________________ Date: ___________________________

My signature above authorizes the Department of Financial and Professional Regulation to reduce the amount of this check if the amount submitted is not correct. I understand this will be done only if the amount submitted is greater than the required fee, but in no event shall such reduction be made in an amount greater than $50.

INCOMPLETE REINSTATEMENT: Incomplete forms will be returned and result in a substantial delay in the reissuance of your license. Please assure your reinstatement includes the following:

? Reinstatement form must be completed in full, include the required fee and a signature. ? Fee must be a check or money order, payable to the Illinois Department of Financial and Professional Regulation. Do

not mail cash. ? Verify the appropriate fee amount. ? Include any necessary and required supporting documentation such as: Proof of CE and completion of the

CCA Form (if applicable). Verification of the requirements are available on our website: idfpr.

SEND ALL REQUIRED INFORMATION AND PAYMENT TO:

IL486-2376 4/22

ILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION DIVISION OF PROFESSIONAL REGULATION POST OFFICE BOX 7450 SPRINGFIELD, IL 62791-7450

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